Part B Insider - 2006 Issue 1
Reader Questions: Encourage 'Negative' for ROS and PFSH
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Article Overview
This reader Q&A explains documentation language used in evaluation and management records, with emphasis on how auditors may interpret certain phrases in review of systems and past family/social history. It discusses guidance drawn from the 1995 documentation guidelines and why wording choices can matter during audit review for physicians and coding staff.
Why This Topic Matters
Accurate documentation language can affect audit defensibility and whether a note supports higher-level history elements. The article is relevant to coders, auditors, compliance staff, and physicians who document evaluation and management encounters.
Article Sections
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Question
A reader asks about documentation language used for review of systems and past family/social history, and whether the guidance appears in formal documentation rules.
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Answer
The response discusses audit risk, recommended documentation wording, and the role of the 1995 documentation guidelines in supporting a complete review of systems.
What You Will Learn
- How documentation terminology can affect audit review of history elements
- What general documentation guidance is discussed for review of systems
- Why certain wording choices may be viewed as less defensible in audits
- How the article frames the relevance of 1995 documentation guidelines
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians and other documenters
- Billing staff
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